Endocrinopathies from checkpoint inhibitors: Incidence, outcomes, and management.

Immune checkpoint inhibitors are used more and more to treat several types of cancer, significantly extending cancer-free survival. However, concerns are growing about their toxic effects, which are many and varied. Endocrinopathies are some of the most frequently reported adverse effects, and thyroid dysfunction is the most common of these. Here, we review the incidence and severity of each immune checkpoint inhibitor-related endocrinopathy, possible factors related to toxicity risk, and principles of management.

A Diagnostic Conundrum of Distributive Shock: Autoimmune Polyglandular Syndrome Type II.

Autoimmune polyglandular syndrome (AIPS) is a heterogeneous condition characterized by the loss of immune tolerance and resultant dysfunction of multiple endocrine organs. Although this condition is insidious in nature, it frequently presents initially as adrenal insufficiency (AI). For patients in shock, physicians routinely assess for infections, volume depletion as well as cardiogenic and iatrogenic causes of shock. However, the case described in this report emphasizes the need for high suspicion of AI syndrome when the etiology of shock remains unclear after primary assessment. A subsequent evaluation for autoimmune etiology, especially in young adults in appropriate clinical setting, may also be warranted. HOW TO CITE THIS ARTICLE: Kumar MP, Thyagarajan B, Haller N, Ciltea D. A Diagnostic Conundrum of Distributive Shock: Autoimmune Polyglandular Syndrome Type II. Indian J Crit Care Med 2019;23(12):582-583.

Shear and pressure under the first ray in neuropathic diabetic patients: Implications for support of the longitudinal arch.

OBJECTIVE: To assess dynamic arch support in diabetic patients at risk for Charcot neuroarthopathy whose arch index has not yet shown overt signs of foot collapse. METHODS: Two indirect measures of toe flexor activation (ratios: peak hallux pressure to peak metatarsal pressure - Ph/Pm; peak posterior hallux shear to peak posterior metatarsal shear - Sh/Sm) were obtained with a custom built system for measuring shear and pressure on the plantar surface of the foot during gait. In addition, the tendency of the longitudinal arch to flatten was measured by quantifying the difference in shear between the 1st metatarsal head and the heel (Sflatten) during the first half of the stance phase. Four stance phases from the same foot for 29 participants (16 control and 13 neuropathic diabetic) were assessed. RESULTS: The peak load ratio under the hallux (Ph/Pm) was significantly higher in the control group (2.10±1.08 versus 1.13±0.74, p=0.033). Similarly, Sh/Sm was significantly higher in the control group (1.87±0.88 versus 0.88±0.45, p=0.004). The difference in anterior shear under the first metatarsal head and posterior shear under the lateral heel (Sflatten) was significantly higher in the diabetic group (p<0.01). Together these findings demonstrate reduced plantar flexor activity in the musculature responsible for maintaining the longitudinal arch. CONCLUSIONS: With no significant difference in arch index between the two groups, but significant differences in Ph/Pm, Sh/Sm and Sflatten the collective results suggest there are changes in muscle activity that precede arch collapse.

Expanded butterfly plots: A new method to analyze simultaneous pressure and shear on the plantar skin surface during gait.

The current method of visualizing pressure and shear data under a subject's foot during gait is the Pedotti, or "butterfly" diagram. This method of force platform data visualization was introduced in the 1970s to display the projection of the ground reaction force vector in the sagittal plane. The purpose of the current study was to examine individual sub-components of the vectors displayed in Pedotti diagrams, in order to better understand the relationship between one foot region and another. For this, new instrumentation was used that allows multiple Pedotti diagrams to be constructed at any instant during the gait cycle. The custom built shear-and-pressure-evaluating camera system (SPECS) allows for simultaneous recordings of pressure and both components of the horizontal force vector (medio-lateral and antero-posterior) at distinctive regions under one's foot during gait. Data analysis of such recordings affirms three conclusions: (i) pressure and shear values on individual sites on the plantar surface of the foot are not associated in a linear manner, (ii) force vectors in the heel and forefoot regions exhibit horizontal force components that oppose one another, and similarly, (iii) force vectors in the frontal plane transecting the forefoot region also exhibit medial-lateral shear components that counteract one another. This approach sheds light on individual vectors that collectively sum to each vector displayed in a Pedotti diagram. The results indicate that shearing between the foot and the ground is not simply a passive event. The structures of the arches and/or muscular activities are major contributors to the observed interfacial stresses.

Blood glucose levels before and after cognitive testing in diabetes mellitus.

The primary indices of diabetes mellitus (DM), including hemoglobin A1c (HbA1c) and fasting glucose, appear to be only moderately predictive of the cognitive impairments exhibited by patients with DM. There is evidence that in DM the ability to utilize glucose is compromised and the authors hypothesized that this difficulty might be relevant to the study of cognitive function in DM. Thus, the authors examined the relationship between cognitive performance and changes in peripheral glucose from the start to the conclusion of cognitive testing. Individuals who showed decreased glucose levels from the start to the conclusion of cognitive testing performed significantly better than those exhibiting moderate to slight increases in glucose levels from the start to the conclusion of testing. Apparently, the putative utilization of blood glucose rather than the glucose levels prior to or following a cognitive challenge is associated with better cognitive performance primarily on more complex cognitive tests. This brief and inexpensive test of changes in glucose levels has potential clinical implications for assessing cognitive status in DM.